by Barbara Ebel
“So,” she said with emphasis, “nothing glaring pokes out at my novice eyes, and you have not mentioned an abnormality.”
He read the name tag clinging to her breast pocket. “Dr. Tilson, the CT scan of this patient’s head is negative. The scan was not particularly useful except for giving you a radiology lesson.”
She sighed. “Thank you for that. I suppose this is good news for our national park ranger, but it still leaves us in a quandary.”
“Let me dictate the report, and then you can bring these materials to your team.”
Annabel waited, bought a premade turkey sandwich from the cafeteria, and headed upstairs. Before gobbling down her sandwich, she found Dr. Schott hunched over Jae Nixon’s chart at the nurses’ station.
Before she could say a word about the CT in her hands, he pointed to the chair beside him and she sat down.
Her chief wore a serious frown; she worried about a repercussion for what he overheard in the office.
“I was not supposed to hear that private argument between you and Jordan. So I am going to pretend like I never heard it. What transpired is between you and him and for the both of you to work out. Don’t let it interfere with your clinical duties.”
He sighed and gave her a sympathetic look. “Also allow yourself the satisfaction that most unscrupulous acts by certain people come back to bite them in their arse. Hopefully, his day will come.”
Annabel nodded and anxiously bit her lip. “Thanks, Dr. Schott. I have found your observation to be spot-on in the past. I’ll continue to do my best on the wards.” She placed the envelope on the counter. “Here’s Jae Nixon’s CT … straight from the radiologist after hearing his interpretation and dictation. It’s negative.”
“That takes any glaring anatomical brain problem out of the picture and leaves us where we started. However, in your absence, Mr. Nixon is being transferred yet again. To the ICU. He’s lapsed into a coma.”
CHAPTER 13
Annabel and Dr. Burg hustled into Jae’s ICU room where anesthesia had intubated him with an endotracheal tube; the ventilator next to him cycled oxygen and air into his lungs. The swooshing sound was overshadowed by the EKG and pulse oximeter beeps coming from the monitors above.
She grimaced; he had again deteriorated … into a coma.
Melody placed a lumbar puncture tray on the rolling table and, in a cordial tone, barked orders to Annabel and Jae’s nurse. “Roll him laterally on his side and don’t displace his breathing tube. Bring his knees up a bit and slide off the back of his gown.”
The resident slid off her white coat and, with sterile gloves, washed Jae’s lower back with antiseptic solution and skin swabs. After it dried on his back and she placed the drapes, she prepared the needles and tubes.
“Annabel, based on Mr. Nixon’s clinical presentation, you must realize that a spinal tap is the next step in his workup.”
She nodded and carefully watched Melody go ahead with the procedure. The resident injected local anesthetic in his lower lumbar area in case he reacted to the next needle stick and then she inserted the spinal needle between a disk space in the middle of his back. Clear cerebrospinal fluid flowed back from his spinal canal and she let it flow into four plastic test tubes.
“You made that look easy,” Annabel said.
“Because it was. He’s in the perfect position for alignment, but the bigger factor here is his age and body size. Older patients are usually more difficult because they have vertebral bone changes and obese patients are another challenge because of their size.”
Melody finished, appropriately labelled all the necessary samples for the lab, and they settled Jae back in a supine position.
“I’ll go write the orders,” Melody said as she slipped back into her coat and tidied her hair in the mirror over the sink. She turned to Annabel. “Your job is to hand deliver the LP samples to the laboratory. On the way out, we’ll talk to his partner, who is waiting for an update.”
-----
In the waiting room outside the ICU, Patty Caye’s eyes grew big and she stood quickly as Melody and Annabel approached.
“Ms. Caye,” Dr. Burg said, “we attended to your coworker expeditiously, but we’re sorry it took this long.”
“The nurses told me downstairs he was sent here. He is in serious condition, isn’t he?”
“Yes. At the moment. He’ll receive supportive care in the ICU while we try to get to the bottom of his illness. The CT scan of his head was normal and we just did a spinal tap.” She frowned. “You know … he’s been unconscious.”
“But while we all wait, isn’t he just rotting away with whatever he has and not getting better?”
“The tap results should shed light on his situation no matter what. But try not to worry as we wait on further lab results and cultures. We’ll empirically start him on IV anti-bacterials.”
Her dazed expression began to fade. “Thank you. Please keep me posted. I’ll help contact his parents and try and visit again tomorrow. In the meantime, I must hurry back to work.”
All three of them scurried away … Annabel for her scut work, Melody to see another patient, and Patty Caye to staff Cincinnati’s National Historic Site.
As the ranger drove away from the hospital, the frown on her face registered her disapproval that, besides Jae, she had been absent for the visitors, volunteers, and temporary ranger on a Saturday afternoon.
-----
As the sun went down and the lights in the hospital blared brighter with intensity, Annabel finally snuck away with her overnight bag to a call room. That was one perk of this hospital, she thought. A separate sleep room all to herself. A luxury. She put toiletries in the adjoining bathroom inside the room and then sat on the bed with her iPhone in her hand.
She lamented over the argument she had with Nancy. Not seeing her sister all day and leaving her alone at her place didn’t feel right either. If only Nancy understood how contemptuous Jordan really was.
Sorry we argued, Annabel texted, especially over dating material. Men aren’t worth it for us to exchange heated words with each other.
She lingered only a second, sent it, and then brushed her teeth and washed her face while she had the opportunity; she still needed to grab some kind of dinner.
Annabel left the call room as Stuart was coming the other way, seeking out a place to bunk down for the night like her.
He held a Styrofoam cup and stopped. “I just overheard scuttlebutt in the ER. A previous patient from our team just came in by ambulance. A nurse peeked at the old chart and mentioned seeing Dr. Watt’s, Dr. Schott’s, and your name.”
“Do you think he or she will end up my patient again?”
“Makes sense since you’re up next anyway.”
“Thanks for letting me know.”
Annabel continued, but now skipped a trip to the cafeteria and went to the ER. She sauntered in, curious why Dr. Schott had not paged her yet. Patients’ stalls were draped closed, a tech pushed an X-ray machine, and a loud conversation could be heard somewhere closer to the admitting door. Her upper level teammates were not in sight.
She glanced up and down the whiteboard, but no patient’s name looked familiar to her.
A muscular orderly came her way, wheeling a stretcher past her and shaking his head. Their gazes met.
“Some man is firing off ballistics at a doc down there,” he said. “I’m parking this somewhere else.”
Annabel tilted her head towards the back of the hallway as he passed. Although there was no major trauma room down there like ones found in a university hospital, a designated room for emergencies still existed. She padded that way in her comfortable clogs, the yelling growing louder as she went.
A tall man stood agitated, half-in, half-out of the doorway to the primary room for stat emergencies. She recognized him - the son of the woman who they had treated for atrial fibrillation - the man who had twin sisters.
The man shouted into the room.
“Death is th
e ultimate mistake and outcome. She was too young for this and she came to you for help. You needed to be proactive with her discharge medications and not leave a possible sequela of her diagnosis to chance. You, your team, and this hospital can’t take back your negligence. It’s too late for that.”
Annabel trembled with fear. She guessed it was Donn Schott or Chineka Watt inside taking the verbal beating. “Mr. Helm,” she vaguely heard Donn say from inside, but he was verbally cut off.
“I can tell you this,” the man screeched. He flung his arm out and pointed defiantly. “I’ll need a year to grieve over this, but I won’t be through the initial shock before I hire a malpractice attorney. If I have anything to do with it, your career is finished before you start. You’ll have no more road to drive on.”
The man turned and stormed out the automatic doors. It happened so fast, Annabel finally remembered to breathe. She treaded a few steps and peeked into the room.
Donn stood against a stretcher with a body on it, covered to the shoulders with a sheet - a woman’s body - Mrs. Helm. Dr. Schott’s eyes, glazed over, stared straight past Annabel.
Off to the side, huddled against counters, was one paramedic and a nurse. There was the lack of a usual mess after a trauma patient comes in with massive injuries and there was no chaos after a non-trauma medical resuscitation. No extra carts, equipment, or uncharted documents or paperwork littered the area. It was like the woman was transported to the hospital by the paramedics … already dead.
-----
Annabel sneaked away without speaking to Dr. Schott. Not that he would bother with her anyway. This was one of those instances, she recognized, where medical students were impotent of any importance in the scheme of things. Donn had “senior” tasks to take care of and she didn’t envy him. Paperwork and a death certificate were one thing, but the tirade directed at him was not justified at all. She shuddered, wondering how any chief resident would or could get over that.
She guessed, at some point, the team would hear about the case. Meagan Helm’s atrial fibrillation must have been a time bomb. But who could predict what would happen to her when she left the hospital, or any patient, for that matter? Despite the current standard of care being implemented, a patient could disprove the odds for improvement, or for that matter, be struck accidentally by a car in the parking lot.
Must someone always take the blame or be responsible for an unforeseen event? she wondered.
Annabel headed for the cafeteria but changed her mind and ambled back to the call room because she didn’t feel like eating. With a sigh of relief that she didn’t bump into Jordan, she went in and glanced at her iPhone. No return message from Nancy. Maybe her sister was giving her the silent treatment.
She slipped under the sheet, resolved to get some sleep, and thought about Bob. She had a lot to tell him but, more importantly, she wondered how he was feeling.
-----
The alarm clock buzzed in Annabel’s room, making her more startled to realize she had slept through the night. Post-call rounds were scheduled with Dr. Mejia, and after the busy work, she’d be sprung from the hospital for a real and long afternoon off.
She showered, changed into clean scrubs, and headed to the ICU. The usual morning nurse smiled at her next to the coffeemaker and Annabel poured them both a cup of vanilla roast.
“Who’s your patient in here or are you stealing our coffee like everybody else does?”
“I do that as well, but I’m the student taking care of Jae Nixon.”
“Family members and friends filtered in yesterday. Didn’t stay at his bedside very long. It scares lay people off when they see someone lying in a coma, on a ventilator, and hooked up to machines that seem to be the only barrier between them and death.”
Annabel nodded. “So true. I don’t blame them. Do you know if there are any spinal tap results back on him?”
“The secretary’s been filing lab work on all the patients, but I haven’t seen them.”
Annabel finished and went first to evaluate Jae. Saddened by his condition, she peeled her eyes off of his facial features, where the tape across his lips held the endotracheal tube in place. His picturesque tattoo didn’t move with the normal flexion and extension of his biceps. She sighed and carefully noted every one of his vital signs - all normal and without the need for pressure support IV drugs.
After listening to his lungs and heart, she went to the desk. She found more regular blood work results, but nothing back on the spinal tap. She knew … she would have had another patient this morning except that Mrs. Helm didn’t make it.
In the office, Annabel said good morning to everyone and sat next to Donn. He was mentally conflicted and stared at a bloodstain on his scrubs. Stuart was flipping pages in his medicine handbook, and the two residents wore circles under their eyes. When Jordan came in, he lived up to her expectations and avoided her with a wide berth.
No one said a word and, finally, Dr. Mejia poked his head in. “Time for rounds. This morning isn’t getting any earlier.” He smiled and pulled at the lapel of his sports coat. He held his eyes on Donn for a bit longer and Annabel gathered they’d been in contact … maybe he knew about the Meagan Helm situation.
As they set out, Dr. Mejia talked softly with Dr. Schott. The attending’s head shook back and forth more than Donn’s and once he patted his colleague on the shoulder. Annabel trotted behind them and strained to hear the conversation.
“Donn,” Dr. Mejia said, “lawsuits in practice are inevitable. I’m just so sorry your first one is going to happen so soon.”
“I’m not even an attending yet,” Donn said despondently. “And I, or we, followed accepted protocol and our clinical judgment.”
Dr. Mejia stopped, had the students fetch charts on patients, and then signaled them into a circle.
“As a team,” Dr. Mejia said, “we were inflicted with an incident last night. I bring it up because this type of situation is a reality for all of us, now and in our entire future careers. Whether or not legal ramifications are deserved or not, you will all suffer from a medical lawsuit.
“Our patient, admitted and discharged recently for atrial fibrillation,” Dr. Mejia continued, “was brought in by paramedics late yesterday and was dead on arrival. We suspect that her atrial fib came back, with a rapid ventricular response while she was home alone.
“As we know, we found out she had mitral stenosis secondary to rheumatic heart disease. We believe she developed acute pulmonary congestion. Her son found her and called EMS too late. She could have also had a major stroke.”
He let the group think about that.
“Is there a question about the care she received?” Jordan asked.
“That’s part of it. We had discussed at length our decision for her discharge. Chronic atrial fibrillation warrants anticoagulation since it minimizes the risk of embolization and stroke. She wasn’t your patient, Dr. Maldonado, but you should know the risk-assessment tools we used for our decision.”
“Yes,” Jordan beamed. “Multiple factors made her a less likely candidate for oral anticoagulation: her younger age, her lack of hypertension, diabetes, and history of stroke. She also didn’t have a history of atrial fib which categorized her as ‘chronic.’”
“Well done. You are paying strict attention to your area of interest. Anyway, the family is boiling mad. They probably went to the internet, read a little bit on the subject matter, which makes them experts, and are hiring an attorney to sue Dr. Schott, me, and the hospital for negligence.”
Chineka Watt winced. She could be involved as well.
“Maybe the family will reconsider,” Annabel said, “once the reality of the situation sinks in. Perhaps with the shock of their mother dying, the grown kids are displacing their emotions on the care she received rather than their loss.”
Dr. Schott sighed and rubbed his beard, but he continued to stand inches back out of their circle.
“And you could make a good psychiatrist,” Dr. Mejia sai
d, glancing at Annabel.
“In any case, besides following the standard of care, always do what your clinical experience and hearts tell you to do for the benefit of your patient. The chances of a bad outcome when you do all those are small. What happened with Mrs. Helm is a one in a thousand probability.
“We must keep our wits, not change our perspective, on how we treat our patients, and handle legal battles with courage and truthfulness.”
CHAPTER 14
Dr. Mejia glanced into the window of Jae Nixon’s ICU room as the team continued on Sunday morning post-call rounds.
“I heard,” he said, “we admitted a national park ranger in a coma.”
Jordan Maldonado’s ears perked up. Often, rounds were the first time he would hear about the other students’ patients. He thought back to yesterday when a female ranger in the cafeteria talked on the phone about her partner being in the hospital. Chances are, he thought, this patient must be her partner. The woman’s discussion had also covered someone else in her life who was ill and had been diagnosed with the unusual disease he had indexed and read about.
“Dr. Burg and Dr. Tilson are on his case,” Donn said. When he added no more information, Dr. Mejia looked at Annabel.
“Dr. Tilson, go ahead.”
Annabel swallowed her nervousness and began her presentation of the patient.
“Jae Nixon is a thirty-five-year-old white male who came into the ER about a week ago and was diagnosed with the flu. He returned yesterday, brought in by his partner, complaining that he was not getting better. His partner also shed light on his history. Mr. Nixon’s malaise and overall flu-like symptoms were worse. His headache was still there, he had a low grade fever, nausea, vomiting, sensitivity to light, and he had developed confusion and some stiffness in his neck.
“Mr. Nixon has no allergies, doesn’t smoke, drinks occasionally, and works as a national park ranger here in Cincinnati.”
She shifted her weight to the other foot. “His past medical and surgical history are both negative. Not even a strep throat or a tonsillectomy.
